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Ayurvedic Medicine: In Depth

Is Ayurvedic Medicine Safe?

Some Ayurvedic preparations may contain lead, mercury, or arsenic in amounts that can be toxic.

Is Ayurvedic Medicine Effective?

A few studies suggest that Ayurvedic preparations may reduce pain and increase function in people with osteoarthritis and help manage symptoms in people with type 2 diabetes, but most of these trials are small or not well-designed. There is little scientific evidence on Ayurveda ’s value for other health issues.

How much do we know about Ayurvedic medicine?

Although Ayurvedic medicine and its components have been described in many scholarly articles, only a small number of clinical trials using these approaches have been published in Western medical journals. About 240,000 American adults use Ayurvedic medicine.

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The ancient Indian medical system, also known as Ayurveda, is based on ancient writings that rely on a “natural” and holistic approach to physical and mental health. Ayurvedic medicine is one of the world’s oldest medical systems and remains one of India’s traditional health care systems. Ayurvedic treatment combines products (mainly derived from plants, but may also include animal, metal, and mineral), diet, exercise, and lifestyle.

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Few well-designed clinical trials and systematic research reviews suggest that Ayurvedic approaches are effective.

Results from a 2013 clinical trial compared two Ayurvedic formulations of plant extracts against the natural product glucosamine sulfate and the drug celecoxib in 440 people with knee osteoarthritis. All four products provided similar reductions in pain and improvements in function.

A preliminary and small NCCIH-funded 2011 pilot study with 43 people found that conventional and Ayurvedic treatments for rheumatoid arthritis were similarly effective. The conventional drug tested was methotrexate and the Ayurvedic treatment included 40 herbal compounds.
Outcomes from a small short-term clinical trial with 89 men and women suggested that a formulation of five Ayurvedic herbs may help people with type 2 diabetes. However, other researchers said inadequate study designs haven’t allowed researchers to develop firm conclusions about Ayurveda for diabetes.
Turmeric, an herb often used in Ayurvedic preparations, may help with ulcerative colitis, but the two studies reporting this were small—one, published in 2005, included 10 people while the other, published in 2006, had 89.

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Some Ayurvedic preparations include metals, minerals, or gems. The U.S. Food and Drug Administration warns that the presence of metals in some Ayurvedic products makes them potentially harmful.
A 2015 published survey of people who use Ayurvedic preparations showed that 40 percent had elevated blood levels of lead and some had elevated blood levels of mercury. About one in four of the supplements tested had high levels of lead and almost half of them had high levels of mercury.
A 2015 case report published in the Center for Disease Control’s Morbidity and Mortality Weekly Report linked elevated blood lead levels in a 64-year-old woman with Ayurvedic preparations purchased on the Internet.
Although rare, Ayurvedic products may cause arsenic poisoning.

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NCCIH is funding research that:

Builds on earlier investigations in breast cancer survivors that found a positive effect of integrated Ayurvedic medicine on improved quality of life; new research will evaluate ways to make this intervention easier to incorporate into peoples’ lives. The proposed Ayurvedic intervention includes diet, lifestyle, yoga , and pressure point treatment.
Studies the mechanism by which an extract from Butea monosperma (BME) flowers may protect against joint destruction from osteoarthritis (BME is widely used in Ayurveda for arthritis and other inflammatory diseases in India).

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Don’t use Ayurvedic medicine to postpone seeing a conventional health care provider about a medical problem.
If you have a health condition, talk with your conventional health care provider before using Ayurvedic products.
There is no significant regulation of Ayurvedic practice or education in the United States, and no state requires a practitioner to have a license. For more information on credentialing complementary health practitioners, see the NCCIH fact sheet Credentialing, Licensing, and Education .
If you’re pregnant or nursing, be sure to consult your (or your child’s) health care provider as some Ayurvedic products may contain products that could be harmful.
Tell all your health care providers about any complementary or integrative health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

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Breeher L, Mikulski MA, Czeczok T, et al. A cluster of lead poisoning among consumers of Ayurvedic medicine . International Journal of Occupational and Environmental Health . 2015;21(4):303-307.
Chopra A, Saluja M, Tillu G, et al. Ayurvedic medicine offers a good alternative to glucosamine and celecoxib in the treatment of symptomatic knee osteoarthritis: a randomized, double-blind, controlled equivalence drug trial . Rheumatology . 2013;52(8):1408-1417.
Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002–2012 . National health statistics reports; no. 79. Hyattsville, MD: National Center for Health Statistics. 2015.
Furst DE, Venkatraman MM, McGann M, et al. Double-blind, randomized, controlled, pilot study comparing classic Ayurvedic medicine, methotrexate, and their combination in rheumatoid arthritis . Journal of Clinical Rheumatology . 2011;17(4)185-192.
Koch I, Moriarty M, House K, et al. Bioaccessibility of lead and arsenic in traditional Indian medicines . Science of the Total Environment . 2011;409(21):4545-4552.
Kuptniratsaikul V, Dajpratham P, Taechaarpornkul W, et al. Efficacy and safety of Curcuma domestica extracts compared with ibuprofen in patients with knee osteoarthritis: a multicenter study . Clinical Interventions in Aging . 2014;9:451-458.
Kurian GA, Manjusha V, Nair SS, et al. Short-term effect of G-400, polyherbal formulation in the management of hyperglycemia and hyperlipidemia conditions in patients with type 2 diabetes mellitus . Nutrition . 2014;30(10):1158-1164.
Meiman J, Thiboldeaux R, Anderson H. Lead poisoning and anemia associated with use of Ayurvedic medications purchased on the Internet—Wisconsin, 2015 . Morbidity and Mortality Weekly Report . 2015;64(32):883
Sridharan K, Mohan R, Ramaratnam S, et al. Ayurvedic treatments for diabetes mellitus . Cochrane Database of Systematic Reviews . 2011;(12):CD008288. Accessed at http://www.cochranelibrary.com on June 23, 2016.
Taylor RA, Leonard MC. Curcumin for inflammatory bowel disease: a review of human studies . Alternative Medicine Review . 2011;16(2):152-156.
White B, Judkins DZ. Clinical inquiry. Does turmeric relieve inflammatory conditions? Journal of Family Practice . 2011;60(3):155-156.

Other References

Darvesh AS, Aggarwal BB, Bishayee A. Curcumin and liver cancer: a review. Current Pharmaceutical Biotechnology . 2012;13(1):218-228.
Patwardhan B. Bridging Ayurveda with evidence-based scientific approaches in medicine. EPMA Journal . 2014;5(1):19.
Pinto B, Goyal P, Flora SJ, et al. Chronic arsenic poisoning following Ayurvedic medication. Journal of Medical Toxicology . 2014;10(4):395-398.
Singh HK. Brain enhancing ingredients from Ayurvedic medicine: quintessential example of Bacopa monniera , a narrative review. Nutrients . 2013;5(2):478-497.

Acknowledgments

NCCIH thanks Dr. David Shurtleff, Deputy Director of NCCIH, and Dr. Craig Hopp, Deputy Director of NCCIH’s Division of Extramural Research for their review of the 2019 update of this fact sheet.

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Research, biomedicine and Ayurveda: From evidence-based medicine to evidence-informed healthcare

Affiliations.

1 Dr D Y Patil Vidyapeeth (DPU), Pimpri, Pune 411 018 INDIA.
2 Former Deputy Director General Sr. Grade (ICMR), Vice President, Forum for Ethics Review Committees in India (FERCI), TC 16/1051-10 CEEMAX Centre, CS Road, Jagathy, Trivandrum 695 014 INDIA.
3 AYUSH Centre of Excellence, Centre for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune 411 007.
4 AYUSH Centre of Excellence, Centre for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune 411 007 INDIA.
PMID: 34666973
DOI: 10.20529/IJME.2021.039

As the search for effective treatment for Covid-19 intensifies, traditional medicine systems are receiving increasing attention from researchers as well as the public. While scientific rigour is non-negotiable, there remain fundamental issues to be addressed when bringing evidence from traditional systems. Here we examine some of these issues pertaining to Ayurveda and the underlying philosophical underpinnings, and suggest potential ways to move forward. We find an ability to emerge from the cage of "biomedicalism" and its foundational reductionism essential for appropriate research in Ayurveda. We caution against pursuing research in Ayurveda by just mimicking modern medicine and highlight the need for appropriate use of modern science tools and methods to understand Ayurveda and explore its potential for healthcare. We emphasise the need and potential for transdisciplinary research in Ayurveda. A balance between evidence-based medicine and evidence-informed healthcare is required.

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01 July 2020

Time to bring scientific rigour to the complex challenge of Ayurvedic medicine

A selection of foods and plants used in traditional medicines. © Marilyna/iStock/Getty Images Plus

A disclaimer first — herbal supplements and Ayurvedic medicines are not synonymous.

The ongoing COVID-19 pandemic shows that age, co-morbidities and the quality of available healthcare impact the rate of recovery. Given that no vaccine or targeted therapeutics for COVID-19 are in ready sight, India’s Ministry of AYUSH, which focuses on traditional Indian medicines including Ayurveda, has called attention to traditional medicines for alleviating symptoms of COVID-19 1 . However, in the absence of scientific evidence of cure and safety, Ayurvedic medicines cannot become part of the standard of care for COVID-19 therapy or management. Can there be a way forward toward scientifically rigorous examination of potential benefits of Ayurveda in COVID-19 management or therapy?

The advertized benefits of herbs in many Ayurvedic products fall in the realm of nutritional supplements where wellness industries thrive. Such wellness products neither claim, nor are their regulatory approvals based on, any definitive therapeutic, medicinal or disease curative benefits. Ayurvedic medicines should not be confused with nutraceuticals, the latter only means food supplement with potential health benefits. Ayurvedic medicines or formulations on the other hand are prescribed by practitioners who claim a curative therapy against a given disease.

And therein lies the barrier to their acceptance as scientifically proven safe medicines for the disease in question: traditional medicinal mitigation of severe acute respiratory infections (SARI), like COVID-19, have not been scientifically proven 2,3 .

Reductionism and the streetlight effect in validating Ayurveda

While traditional medicines from Ayurveda or traditional Chinese medicine (TCM) encompass the use of traditional medicinal concoctions, they are also are known sources of discovery for phytopharmaceuticals 4,5 : that is, individual chemicals isolated from a given medicinal herb that can mitigate a disease or its associated symptoms. In the latter approach, chemists try to identify the key molecules from a herb for its ability to mitigate, say, disease symptoms that are demonstrable in an animal model or in cell lines — in the parlance of the conventional drug industry, they seek the active pharmaceutical ingredient. Recent approval for a clinical trial of phytopharmaceuticals for COVID-19 is one such example 6 . The molecule, AQCH, is derived from the broom creeper Cocculus hirsutus , a plant traditionally used for its medicinal benefits.

Pursuing such a ‘reductionist’ methodology is not surprising since mechanisms of actions of individual phytopharmaceuticals are relatively easier to resolve than those of Ayurvedic medicines, which are often combinations of multiple herbs that are believed to act in synergy and prepared by complex traditional methods. And the merit of a reductionist, phytochemical, approach is not unfounded. The anti-malarial drug, artemesinin, after all was discovered by this approach, starting with a medicinal herb Artemisia annua 7 .

Therefore, approaches to discover phytopharmaceuticals from traditional medicines, TCM or Ayurveda, are likely to bring tangible rewards when pursued with sufficient scientific rigour. These promises notwithstanding, this approach may hit a road block when seeking a treatment for COVID-19, in which clinical presentation of patients is complicated by co-morbidities that are unlikely to be addressed by a single phytopharmaceutical agent.

Moreover, this approach to phytopharmaceutical discovery calls to mind Noam Chomsky’s observation on the scientific method: “Science is a bit like a joke about the drunk who is looking under a lamppost for a key that he has lost on the other side of the street, because that is where the light is. It has no other choice”.

Thus, when pathogenesis is partly recapitulated in a cell line, its mitigation by a given phytopharmaceutical is considered therapeutically relevant — what is visible under the ‘streetlight’ of a screening procedure. Other potentially useful phytopharmaceuticals — epistemologically speaking — are then discarded by ignorance.This approach is also antithetical to Ayurvedic principles wherein the totality of the entire medicine/formulation cannot be reduced to its individual components. By the same Ayurvedic rationale, what a patient suffers is the sum total of a host of bodily manifestations, which cannot be reduced to only a single symptomatic manifestation.

Repurposing Ayurvedic medicines

Ayurveda is founded on traditionally inherited knowledge and is based on empirical evidence. Given the recent origin of COVID-19, an Ayurvedic treatment is therefore not available. New Ayurvedic medicines also cannot be discovered — unlike in a drug discovery programme of conventional medicine. Thus, cure or management for COVID19 — if these were to be found in Ayurvedic pharmacopeia of India — would fall under the category of drug repurposing or therapeutic switching, again, in the parlance of the pharmaceutical industry.

The concept of repurposing of medicine is not alien to Ayurveda. The list of medicines, or the combination thereof, that an Ayurvedic practitioner may use to treat symptoms of COVID-19 is not inexhaustible and most practitioners would make overlapping, if not identical, recommendations from the available list of Ayurvedic medicines. Their choice of medicines would be guided by the framework of mapping pathogenesis set out in Ayurvedic classifications of a patient’s constitution and the co-morbidities presented, along with those of COVID-19. Even within this finite choice of medicines, the prescriptions will be customized for individual patients: indeed, there is no universal fit in Ayurvedic therapy.

However, one needs to ask whether such rationale and personalized procedure for Ayurvedic therapeutics could be timely and effective during a pandemic. While one can draw a rosy picture of traditional medicinal panacea for COVID-19, the realities could be challenging. COVID-19 symptoms can escalate precipitously in many patients, requiring emergency care, foreclosing the option of slow-acting Ayurvedic interventions. Also, here is cautionary advice against the use of herbal or traditional medicines for COVID-19 2,3 even though their potential is documented 4,5 .

A clinical trial on Ayurvedic COVID-19 management?

Thus, while Ayurvedic treatment for COVID-19 cannot be suggested, the opportunity presented by the pandemic could be used to rigorously design clinical trials to test the claims of Ayurvedic medicine. Many COVID-19 positive patients display mild symptoms and recover under quarantine with no further treatment, since none may be available yet. These patients, not requiring hospitalization, could form ideal cohorts for randomized control trials to validate Ayurvedic alleviation of COVID-19. A clear and realistic definition of anticipated outcomes from such clinical trials and their rigorous design might answer questions including whether Ayurvedic therapy can help early and improved recovery of COVID-19 patients, or whether such an intervention can reduce the number of patient requiring critical care.

Animal models

Safety and toxicity assessments of Ayurvedic medicines are possible using the standards of evaluation practiced in mainstream pharmaceutical sciences: for instance, by using animal models to assess toxicity and also recapitulation of severe acute respiratory infections in mouse models for testing actual mitigation.

Ayurvedic medicinal claims can also be tested in carefully constructed animal models of human diseases to assess the cross-talk between Ayurvedic medicines and immune system and gut microbiome, an over-looked field, to reveal as yet mysterious ways of working of Ayurvedic medicines. Quality assurances to overcome the varying medicinal properties of plants under different geographical conditions can also be resolved.

These steps can address the major concerns about efficacy and safety of Ayurveda, while technological breakthroughs in the coming years may turn on the many streetlights to illuminate the space of complex Ayurvedic formulations.

(*Jitendra Kumar is from the Bangalore Bioinnovation Center, Bengaluru and **Pradip Sinha is from the Indian Institute of Technology Kanpur.)

[Nature India Special Issue: COVID-19 Crisis]

Nature India’s latest coverage on the novel coronavirus and COVID-19 pandemic here . More updates on the global crisis here .

1. Ministry of AYUSH. Government of India Gazette notification F. No. L1101/8/2020/AS (21 April 2020)

2. Cyranoski, D. China is promoting coronavirus treatments based on unproven traditional medicines. Nature (2020) doi: 10.1038/d41586-020-01284-x

3. Yang, Y. Use of herbal drugs to treat COVID-19 should be with caution. Lancet 395, 1689–1690 (2020)

4. Redeploying plant defences. Nature Plant. 6, 177 (2020) doi: 10.1038/s41477-020-0628-0

5. Cui, H.-T. et al. Traditional Chinese medicine for treatment of coronavirus disease 2019: a review. Traditional Medicine Res. 20, 65–73 (2020) doi: 10.12032/TMR20200222165

6. ICGEB with Sun Pharma: Phase-II clinical trial on AQCH for treatment of COVID-19 patients. Press Release

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doi: https://doi.org/10.1038/nindia.2020.101

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What is Ayurveda?

Ayurveda, a natural system of medicine, originated in India more than 3,000 years ago. The term Ayurveda is derived from the Sanskrit words ayur (life) and veda (science or knowledge). Thus, Ayurveda translates to knowledge of life . Based on the idea that disease is due to an imbalance or stress in a person's consciousness, Ayurveda encourages certain lifestyle interventions and natural therapies to regain a balance between the body, mind, spirit, and the environment.

Ayurveda treatment starts with an internal purification process, followed by a special diet, herbal remedies, massage therapy, yoga, and meditation.

The concepts of universal interconnectedness, the body's constitution ( prakriti ), and life forces ( doshas ) are the primary basis of ayurvedic medicine. Goals of treatment aid the person by eliminating impurities, reducing symptoms, increasing resistance to disease, reducing worry, and increasing harmony in life. Herbs and other plants, including oils and common spices, are used extensively in Ayurvedic treatment.

In India, Ayurveda is considered a form of medical care, equal to conventional Western medicine, traditional Chinese medicine, naturopathic medicine, and homeopathic medicine. Practitioners of Ayurveda in India undergo state-recognized, institutionalized training. Currently, Ayurvedic practitioners are not licensed in the United States, and there is no national standard for Ayurvedic training or certification. However, Ayurvedic schools have gained approval as educational institutions in some states.

Ayurveda can have positive effects when used as a complementary therapy in combination with standard, conventional medical care.

Many Ayurvedic materials have not been thoroughly studied in either Western or Indian research. Some of the products used in Ayurvedic medicine contain herbs, metals, minerals, or other materials that may be harmful if used improperly or without the direction of a trained practitioner. Ayurvedic medicines are regulated as dietary supplements rather than as drugs in the United States, so they are not required to meet the safety and efficacy standards for conventional medicines. These medicines can interact, or work against, the effects of Western medicines. Investigate the training and background of Ayurvedic practitioners whom you intend to use.

It's important to discuss any Ayurvedic treatments that you use with your doctor. Women who are pregnant or nursing, or people who are thinking of using Ayurvedic therapy to treat a child, should consult their healthcare provider. It is important to make sure that any diagnosis of a disease or condition has been made by a healthcare provider who has substantial conventional medical training and experience with managing that disease or condition. While Ayurveda can have positive effects when used as a complementary therapy in combination with standard, conventional medical care, it should not replace standard, conventional medical care, especially when treating serious conditions.

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Bridging Ayurveda with evidence-based scientific approaches in medicine

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Published: 01 November 2014
Volume 5 , article number 19 , ( 2014 )

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Bhushan Patwardhan 1

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This article reviews contemporary approaches for bridging Ayurveda with evidence-based medicine. In doing so, the author presents a pragmatic assessment of quality, methodology and extent of scientific research in Ayurvedic medicine. The article discusses the meaning of evidence and indicates the need to adopt epistemologically sensitive methods and rigorous experimentation using modern science. The author critically analyzes the status of Ayurvedic medicine based on personal observations, peer interactions and published research. This review article concludes that traditional knowledge systems like Ayurveda and modern scientific evidence-based medicine should be integrated. The author advocates that Ayurvedic researchers should develop strategic collaborations with innovative initiatives like ‘Horizon 2020’ involving predictive, preventive and personalized medicine (PPPM).

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Ayurveda is one of the traditional systems of medicine that practices holistic principles primarily focused on personalized health. Originated in India, Ayurveda is one of the ancient yet living health traditions. Ayurveda is commonly referred as ‘science of life’ because the Sanskrit meaning of Ayu is life and Veda is science or knowledge. Charaka Samhita , Sushruta Samhita (~400 BC–200 AD) and Ashtanga Hridaya of Vagbhata are main classics, which give detailed descriptions of over 700 herbs and 6,000 formulations. Madhav Nidan (~800 AD), a diagnostic classic, provides over 5,000 signs and symptoms. Life in Ayurveda is conceived as the union of the body, senses, mind and spirit. The concept of Prakriti or individual nature has a central role in Ayurveda therapeutics. With over 400,000 registered Ayurveda practitioners, the government of India has a formal structure to regulate its quality, education and practice.

Prolonged use of Ayurveda by people has also led to several home remedies for common ailments. Ayurvedic medicines contain sophisticated therapeutic formulations. Ayurveda is also a person-centered medicine (PCM), which deals with healthy lifestyle, health promotion and sustenance, disease prevention, diagnosis and treatment [ 1 ]. The holistic concepts of Ayurveda give emphasis to health promotion, disease prevention, early diagnosis and personalized treatment. There seem to be substantial similarities between the traditional systems like Ayurveda and the innovative approach of predictive, preventive and personalized medicine (PPPM) [ 2 ]. The Horizon 2020 initiative of the European Union rightly considers PPPM as the hardcore of its strategy [ 3 ].

The need for scientific evaluation of Ayurveda has been recognized for a long time [ 4 ]. Ayurveda has personalized approach involving constitutional assessment, which can guide primary prevention, diagnosis and therapeutics. Ayurveda also offers detailed guidance about food, nutrition and diet as per the individual constitution or Prakriti as well as seasons [ 5 ]. The scientific value of basic principles of Ayurveda like Prakriti is being studied in context to biology and genomics [ 6 ].

Ayurveda as an ancient science of life has a long history, and its basic principles may be valid even today. However, essence of any science is a continuous quest for new knowledge through research, development and newer applications. The mode of manifestation of disease has changed. The geo-climatic environment, plants, animals and microbes have changed. Human behavior, lifestyle and genetics have changed. Clearly, classical Ayurveda of yesteryears cannot be blindly practiced without contemporary modifications. Continuous research on safety, quality and efficacy of Ayurvedic drugs and procedures is needed. Systematic documentation and critical analysis of clinical practice are necessary. Sanskrit savvy scholars from India should not be considered as the only custodians of knowledge and practice of Ayurveda. Several Western scholars like Meulenbeld have contributed to emergence of the new Ayurveda [ 7 ]. Many countries in the world especially Germany, Italy, Hungary, Switzerland, United States have institutions where Ayurveda is correctly practiced with respect to traditions and high professional competence [ 8 , 9 ].

Ayurveda was meant to be open for new ideas, principles and knowledge for continuous and systematic progress. However, its progression seems to be stalled during the last several centuries resulting in chronic stagnancy of today. Heritage pride and past glory-based emotional attitudes seem to be predominant among practitioners as against evidence-based quest of scientific research. There seem to be an evident complacency, defensive and dogmatic attitude and often pure sentimentalism rather than a pragmatic scientific outlook. We need to recognize that emotions, experience and evidence are not mutually exclusive. Becoming modern is not a crime; it does not prevent anyone from maintaining cultural identity. No tradition is a static entity; modernity results from evolving traditions. For instance, Charaka would not have ignored technologies like electron microscope if they had been available during his time [ 10 ]. While accepting modern tools and technologies, it is equally important to respect epistemological value of knowledge system like Ayurveda. Embracing modernity by Ayurvedic community does not mean blind acceptance of Western logic and reductive methodologies. In fact, increased recognition to disciplines like systems biology is indicative of modern science moving towards holistic concepts. Therefore, this may be the opportune time to facilitate integration of Ayurveda, Western biomedicine and modern science.

Recently, many experts and critiques have raised concerns that while the popularity of traditional and complementary medicine (T&CM) is growing, this sector is still grappling to discover appropriate models and demonstrate sufficient scientific evidence [ 11 ]. Ayurvedic medicine is no exception to these concerns. However, for understanding Ayurveda from modern terms, one also needs to understand its epistemology.

The objective of any medical research should be to assess health effects, minimize bias, chance effects and confounders. A well-designed rigorous scientific research on medicines and therapeutic practices of Ayurveda is necessary. The Ayurveda sector has to take cognizance of important initiatives like standards for reporting observational epidemiology (STROBE) and consolidated standards on reporting trial (CONSORT) in the methodological domain to develop epistemologically sensitive appropriate methods. Evidence-based Ayurveda needs appropriate blends of modern science, rigorous trial methods and observational studies. Arguably, the nature of evidence in case of Ayurveda may be different from that of Western biomedicine. The status of Ayurveda as an evidence-based medicine is also reviewed here.

The evidence in right perspective

In philosophy, evidence is closely tied to epistemology, which considers the nature of knowledge and how it is acquired. Many proponents of T&CM sector argue that inability to measure something using present scientific methods is not a proof of its nonexistence. However, inability of measuring something is certainly not a proof of its existence.

It is also argued that future studies involving comparisons of T&CM systems with modern medicine need to be on the leveled playing field for evaluating outcomes from both an allopathic and a whole-system points of view [ 12 ]. Instead of any hierarchy of evidence, a circular model has been proposed to arrive at pragmatic but rigorous evidence which would provide significant assistance in clinical research [ 13 ]. Appreciably, over a period of time, traditional Chinese medicine (TCM) is starting to create large body of scientific evidence to support safety, pharmacology and clinical efficacy [ 14 ]. Ayurvedic medicine also needs to first discover epistemologically sensitive methods and then build objective scientific evidence with reasonable consistency to justify clinical decision making and therapeutics.

Ayurveda epistemology

The epistemology of Ayurveda is based on the relation between microcosm and macrocosm involving five basic elements ( mahabhoota ), three dynamic principles similar to humors ( dosha ), seven types of tissues ( dhatus ) and many other unique concepts. An introduction to basic concepts may be useful for readers who are not familiar with epistemology of Ayurveda [ 15 ]. In general, Ayurveda is experiential, intuitive and holistic, whereas that of the modern medicine is based more on experimental, analytical and reductive reasoning. The relationship between Ayurveda and modern science is similar to the relationship between the ‘whole’ and the ‘parts’, where the sum of the parts need not be equal to the whole [ 16 ]. Modern medicine is based more on rationalism, reductionism with deeper understanding of molecules, cells, organs or diseases as parts. In the process, however, the sight of the whole person seems to have been somewhat neglected. Integrative, whole system approaches like PPPM and PCM as well as traditional and holistic systems like Ayurveda may need epistemologically sensitive research methodology.

Ayurveda is uniquely patient-oriented where the Ayurvedic physician diagnoses, treats and dispenses medicine to every individual patient. This important principle can form the basis for a form of personalized medicine which will give maximum therapeutic efficacy and high safety to a particular person with a particular disorder, under specified conditions depending on individual constitution, and properties of materials. Prakriti specific prescription may also include supportive therapies, diet and life-style advice so as to regain physiological balance, finally resulting in the removal of the disorder. A decision-support system known as AyuSoft (developed by Center for Development of Advance Computing and University of Pune, Ganeshkhind, Pune India) based on Ayurveda knowledge has been shown to be useful in determination of individual Prakriti and personalized treatments [ 17 ].

The conventional, experimental and diagnostic methods based on pathophysiology mostly rely on limited markers as evidence of health [ 18 ]. Applicability of such restrictive approaches to understand complex systems like Ayurveda has been questioned. Person-centered integrative medicine, which considers the whole person, needs new sets of experimental methodology. Holistic complex systems like Ayurveda may need approaches like the Bayesian theory rather than a classical statistical frequentist approach [ 19 ]; however, no serious experimental efforts have been made to test this hypothesis [ 20 ].

Evidence-based medicine

Works of famous scientist Archie Cochrane on efficacy and effectiveness [ 21 ] and meta-analysis as a method of summarizing the results of randomized trials [ 22 ] have led to a powerful research and analysis tool in the form of ‘systematic reviews’, which empowered clinicians and researchers decision making. These efforts finally led to the evolution of evidence-based medicine (EBM) as a new approach to bring more rational and analytical evidence for research-backed practice of medicine [ 23 ]. The principles of EBM consider consistency of clinical practice quality and quality of scientific evidence to develop evidence-based practice.

In the following section, we have critically analyzed present situation regarding these two important aspects and have reviewed the status of Ayurveda as an evidence-based medicine.

Evidence base for Ayurvedic medicine

It is very important to review available evidence in the right perspective. In case of Ayurveda, the evidence can be drawn from two main sources. First, source of evidence may be based on historical, classical and present nature of clinical practice. Here, the documentation of practice to support various claims is very crucial. Mere reference to classical texts is not sufficient as evidence for practice. The second source of evidence may be based on scientific research to support various theories, medicines and procedures used in Ayurvedic medicine. A critical situation analysis of present status of clinical practice and scientific research on Ayurvedic medicine may be necessary at this stage.

Clinical practice

Arguably, the clinical practice of classical Ayurveda is rare. Ayurvedic practitioners are reported to adopt allopathic practices for better acceptance in urban settings [ 24 ]. Although, huge knowledge resource and wisdom is available from many Ayurveda classic books, systematic data on actual use and evidence of reproducible outcomes is not available in public domain. Standard treatment protocols for practitioners are not available. Systematic documentation and reliable data on pharmacoepidemiology and pharmacovigilance for clinical practice, safety and adverse drug reactions are not available as open access, although a modest beginning has been made [ 25 ]. The status of professional [ 26 ] and continuing education [ 27 ] as well as attitudes of practitioners towards safety [ 28 ] are also worrying. As per present regulations in India, no scientific or clinical data is required for manufacture and sale of classical Ayurvedic medicines. Technically, sound pharmacopoeia, good manufacturing practices, quality control and pharmaceutical technologies for Ayurvedic medicine are still evolving [ 29 , 30 ]. Issues related to appropriate research methodologies or treatment protocols for Ayurveda have also not been properly addressed. Many critiques are demanding better coordination between stakeholders, continuous dialogue with scientific community [ 31 ] and total overhaul of the curriculum and pedagogy along with the need for crosstalks between different streams [ 32 ]. Recent report on status of Indian medicine and folk healing indicates the need to strengthen research and use of Ayurveda, yoga, unani, siddha, homeopathy (AYUSH) systems in national health care [ 33 ]. The need for innovation is also urged by thought leaders in this sector [ 34 ]. In short, the evidence base to support good clinical practice, guidelines and documentation in Ayurvedic medicine remains scant and grossly inadequate.

Scientific evidence

Controlled clinical trials are taken as the highest level of evidence. Ayurveda lags far behind in scientific evidence in quantity and quality of randomized controlled clinical trials (RCTs) and systematic reviews. For instance, out of 7,864 systematic reviews in the Cochrane Library, Ayurveda has just one, while homeopathy and TCM have 5 and 14, respectively. Substantial grants have been allocated to ambitious national projects involving reputed laboratories. However, the design, methodology and quality of clinical trial on Ayurvedic medicines seem to lack the expected rigor [ 35 ]. Of course, this does not mean that the RCT model is suitable to clinical research in Ayurveda. RCTs have already been subjected to criticism [ 36 ]. Value of observational studies cannot be ignored. Certainly, there is a need to develop appropriate research methodology for complex whole system, whole-person-centered clinical trials as an alternative to RCTs. Already, scientists are advocating robust clinical study designs based on personalized approach and metabolomics with only one patient [ 37 ]. Thus, non-suitability of RCTs should not be used as an excuse for avoiding rigorous scientific research and clinical documentation.

Few noteworthy attempts related to research and practice include a national program on Ayurvedic biology [ 38 , 39 ], Ayugenomics [ 40 ], whole systems clinical research [ 41 – 43 ], good clinical practices guidelines, digital helpline [ 44 ], decision support system AyuSoft, and systematic reporting standards on lines with CONSORT for Ayurveda [ 45 , 46 ]. Recent efforts to develop robust clinical protocols for comparing effectiveness of complex Ayurvedic and conventional treatments are laudable [ 47 ]. Other notable efforts related to integrative therapy for leishmaniasis have been able to generate sufficient scientific evidence [ 48 ]. Agreeably, many of these efforts could not produce any remarkable products, processes or protocols, and desirable impact on a scientific community is yet to be seen. The need to enhance collaborative culture between Ayurvedic and modern scientific communities has been rightly stressed [ 49 ].

As a result, Ayurvedic medicine continues to remain subcritical in research publications, which is an important indicator of external evidence [ 50 ]. The present scientific evidence in support of Ayurvedic medicine remains extremely poor. The House of Lords and European Union have put several restrictions on Ayurvedic medicines [ 51 ]. Many articles lamenting poor quality of Ayurvedic medicines, presence of heavy metals and other safety compromising substances have been published [ 52 , 53 ]. This situation may lead to further denigration, which can adversely impact the development of evidence base for Ayurveda.

Ayurvedic genomics and epigenomics

According to Ayurveda constructs, doshas are the dynamic principles, which govern a person’s physical, physiological and psychological functions including metabolism. Ayurveda describes three doshas namely vata, pitta, and kapha. The proportional domination of doshas in an individual is expressed as Prakriti , which broadly mean a body type or individual nature. An Ayurvedic physician determines the Prakriti of a patient so as to personalize treatment. The Ayurvedic description clearly suggests that the innate dispositions are represented by individual Prakriti , which represent phenotypes. Classifying humans based on phenotypes still remains a challenge to biomedical science. A number of research groups are now investigating the correlation between Ayurvedic phenotypes and individual human genotypes. A pioneering study showed significant correlation between HLA alleles and Ayurvedic Prakriti type [ 54 ]. Later, it was also hypothesized that different Prakritis may possess different drug metabolism rates associated with drug-metabolizing enzyme polymorphism. In another genotyping study, significant correlations between CYP2C19 genotypes and major classes of Prakriti types have been reported [ 55 ]. A project to study genomic variation analysis and gene expression profiling of human, Prakriti based on the principles of Ayurveda is underway. Now, it is hoped that going beyond genomics is necessary to understand how environment and behaviors can be responsible for inheritable changes when the genome remains unchanged. This science of epigenetics is seen as a future hope to get answers to many puzzles. It is felt that detailed understanding of Ayurvedic concepts like Prakriti may actually facilitate this process. However, no specific genotype has yet been specifically related to a Prakriti type.

Ayurvedic concept and predictive diagnosis

Modern biomedicine recognizes progressive nature of diseases like cancer and diabetes. It is known that slow yet progressive pathophysiological changes result in a transition from a healthy state to diseased state. Ayurvedic concept of shatkriyakaal elaborates a six-stage progressive transition from balanced to unbalanced stage leading to disease manifestation in a person. These six stages are unique and may help early recognition and early diagnosis much before onset of measurable clinical symptoms of diseases. It is possible to undertake a systematic cohort study by stratifying patients in the six categories. Each of the cohorts can be carefully followed up to study pathophysiological, genetic, and epigenetic and metabolomic differences. This may give leads towards the identification of new markers and early predictions, which can then be used for prevention and personalized treatments.

Thus, Ayurveda and PPPM concepts have many similarities, where both do not merely consider concept of disease in isolation but consider the diseased ‘person’. The need to define a common model of health and disease between the western and eastern knowledge systems has been pointed out earlier [ 56 , 57 ]. Therefore, a collaborative project based on concepts of PPPM and Ayurveda may help to better understand disease progression and predictive diagnosis of diseases like cancer and diabetes. In this context, recent efforts to correlate traditional Ayurvedic and modern medical perspectives on cancer are very relevant. In a qualitative study, it was observed that Ayurvedic medicine offers a unique perspective on the biomedical diagnosis of cancer. Due emphasis on restoring wholeness, use of natural remedies focus on emotional health, and emphasis on prevention strategies were found to be unique features of Ayurvedic interventions [ 58 ].

Moving towards evidence base

Several issues need to be addressed for Ayurveda to move towards acceptable evidence base. Concerns related to protocols, problems and potential of Ayurveda in context to evidence-based T&CM have been recently discussed [ 59 ]. Few critiques have opined that basic concepts of Ayurveda should not be distorted to suit convenience or availability of biomedical research models [ 60 ]. Arguably, prevailing pre-clinical methods and clinical models like RCTs may not be suitable to validate Ayurvedic medicine. However, the onus of developing suitable models to build necessary evidence must be voluntarily accepted by the Ayurveda sector. Some efforts in the direction to conduct the whole system clinical trials are already in progress [ 61 ].

A critical review and analysis indicate that the present Ayurvedic medicine is severely deficient in scientific evidence related to clinical practice and scientific research. Ayurveda sector needs to go beyond mere scholarly recitals, reviews and defensive interpretations, which are abundant in current literature. Ayurveda needs to be studied and experimented with help of new models based on modern science and biology. Ayurvedic medicine needs more rigorous scientific research for evaluating safety, quality and efficacy [ 62 ]. Many lessons learned in the past may guide our quest for evidence-based Ayurveda in the future [ 63 ]. It may be worthwhile to learn from collaborative research networks like IN-CAM from Canada [ 64 ] and CAMbrella from Europe [ 65 ]. Ayurveda sector needs to get connected with Indian and global scientific networks not as a bureaucratic process but for scientific and professional pursuits.

Conclusions

This review and analysis is carried out with a caveat that the methods and evidence approach of biomedicine may not be directly applicable to Ayurveda. However, either Ayurveda has to discover its own methodology and approach for evidence or should face the critical analysis as per the conventional approach of EBM. Avoiding any critical appraisal under the pretext that it is a holistic system and that the present methods like randomized controlled trials are not applicable may not sustain for a long time.

The Ayurvedic sector should urgently recognize and address the need for scientific evidence [ 66 ]. Systematic documentation, appropriate methodology and rigorous experimentation in accordance with good practices coupled with epistemologically sensitive approaches will remain crucial to move towards evidenced-based Ayurveda. Key factors crucial for Ayurveda to move towards evidence-based scientific approaches related to quality of drugs and practices are portrayed in Figure 1 . The question of epistemologically sensitive methods is relevant only to biomedical laboratory and clinical research. The good agricultural practices for procurement of raw materials and good manufacturing practices for Ayurvedic drugs must be in accordance with the globally accepted norms.

Key factors for evidence-based Ayurvedic medicine.

Integration of PPPM and Ayurveda

The new philosophy of health care is moving from illness to wellness, from treatment to prevention and early diagnostics and from generalized approach to personalized medicine. As discussed in this review, there are several similarities between the concepts of PPPM and Ayurveda. Search of novel models for integrative medicine indicates the need for collaborations between traditional systems like Ayurveda and contemporary western biomedicine [ 67 ]. Agreeably, many concepts from Ayurveda have not yet been validated with help of modern science. Therefore, it is felt that collaborative efforts between scientific researchers from Ayurveda and PPPM seem to be a mutually beneficial proposition. Such integration bringing the best of the western biomedicine and eastern traditional knowledge systems like Ayurveda may lead to high impact projects. Suitable industry collaborators can also be roped in from both respective regions. Thus, the three dimensional priority of ‘Horizon 2020’ can be effectively addressed through integration of PPPM and Ayurveda. Such integration certainly has contemporary significance and will help to address societal challenges presently faced in the global health care sector.

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Acknowledgements

I thank Gururaj Mutalik and Girish Tillu for their valuable inputs and research assistance. I gratefully acknowledge open access support especially from Google Scholar, Pubmed, and Cochrane Collaboration. Financial support from Board of College and University Development, Savitribai Phule Pune University is gratefully acknowledged.

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Patwardhan, B. Bridging Ayurveda with evidence-based scientific approaches in medicine. EPMA Journal 5 , 19 (2014). https://doi.org/10.1186/1878-5085-5-19

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Integration of Ayurveda and allopathic medicine: Opinion of experts who participated in the working group meetings for the preparation of the WHO benchmarks for the training and practice of Ayurveda

Berra, Jorge Luis

Fundación de Salud Ayurveda Prema, Buenos Aires, Argentina

Address for correspondence: Dr. Jorge Luis Berra, Santa Fe 3373 6 B (1425) Buenos Aires, Argentina. E-mail: [email protected]

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Infographic

The World Health Organization (WHO) has recognized the importance of integrating traditional systems of medicine, including Ayurveda, with conventional medicine, and has taken several initiatives to promote this integration. The Ministry of AYUSH, Government of India, agreed to host two WHO Working Group Meeting that took place at National Institute of Ayurveda (2018) and at Institute of Teaching and Research in Ayurveda (2019) for developing the WHO Benchmarks in Ayurveda with the participation of 27 experts from the six regions of World Health Organization. These WHO Benchmarks on Training and Practice of Ayurveda were published in March 2022. Excluding the author, 23 (89%) of the experts which participated in the said meetings answered a questionnaire about the integration of Ayurveda and allopathic medicine. A very significant majority of these experts (95%) considered that Ayurveda can make important contributions to conventional medicine and are in favor of the integration of Ayurveda and allopathic medicine. There is also a majority consensus that conventional physicians should have training in Ayurveda at both the undergraduate and graduate levels and that they should have training in Ayurvedic remedies. A large proportion of the experts consulted consider the prevailing view in the Ayurvedic government and official environment in India to be in favor of integration with allopathy, and a significant but somewhat smaller number appreciate this same trend in the Ayurvedic academic field of India. It is significant that almost two thirds believe that in the West, Ayurveda should be a specialty within conventional medicine.

Introduction

The World Health Organization (WHO) has recognized the importance of integrating traditional systems of medicine, including Ayurveda, with conventional medicine and has taken several initiatives to promote this integration. The WHO Traditional Medicine Strategy 2014–2023 emphasizes integrating traditional and complementary medicine, including Ayurveda, into national healthcare systems. The strategy includes recommendations for promoting research, regulation, and training in traditional and complementary medicine. [ 1 ] The initiatives from WHO aim to promote the integration of Ayurveda and other traditional systems of medicine with conventional medicine to improve access to safe and effective health care for all.

The Ministry of AYUSH, Government of India, agreed to host the WHO Working Group Meeting

for developing the WHO documents, Benchmark for Practice in Ayurveda, Benchmark for Practice in Unani, and Benchmark for Practice in Panchakarma at the National Institute of Ayurveda, Jaipur, from September 17 to 19, 2018. [ 2 ] The Ministry of AYUSH and WHO organized the International Experts Consultation Meeting for developing the WHO documents Benchmarks for Practice in Ayurveda, Benchmarks for Practice in Unani, and Benchmarks for Practice in Panchakarma and Updating the Benchmarks for Training in Ayurveda, and Benchmarks for Training in Unani which was held at IPGTR&A at Jamnagar, India, November 26–29 2019. After meticulous review processes, in March 2022, they were presented at the Geneva headquarters with the participation of Dr. Tedros Ghebreyesus, General Director of WHO, and Vd. Rajesh Kotecha, Secretary of Ayush, the “WHO Benchmarks for the training of Ayurveda” and “WHO Benchmarks for the practice of Ayurveda.” The “WHO Benchmarks for the Training of Ayurveda” is an update of its previous version published in 2010. [ 3 ]

It could be helpful and relevant to consult the opinion of experts from the six WHO regions about different aspects related to the integration of Ayurveda and conventional medicine.

Materials and Methods

The Ayurveda experts who participated in these meetings have answered a questionnaire related to a Ph.D. research project about “Trends, contributions and challenges in the integration between Ayurveda and allopathic medicine.” The questionnaire was answered on the spot by 21 experts, while two others sent their responses by mail.

Twenty-seven experts participated in the two meetings; eight participated in both meetings, six only in the first and another 13 only in the second. Three people did not answer the questionnaire, and the author of this paper was also excluded from the investigation. The responses of 23 experts who have the following characteristics were considered:

Place of residence: 10 resided in India, 2 in the USA, and another 2 in Malaysia, while only one expert per country attended from Spain, Germany, Italy, Latvia, Mauritius, Switzerland, Tanzania, Russia, and the UAE.
Sex: 17 males and six females
Average age: 52 years
Original training: Ayurveda 16, Allopathy 5, Ayurveda and Allopathy 1, Heilpractitioner 1

Training time in Ayurveda: More than 20 years 18; between 11 and 20 years 2; between 1 and 5 years 1; without training in Ayurveda 2 (members of regulatory offices in their countries of origin) [ Table 1 ].

Today’s globalization allows different visions of health to come into contact. Integrating Ayurveda and allopathic medicine is a complex and highly topical reality that arises both in India and the West. It is of great importance to know, through the verification of authorized opinions, the trends to draw conclusions that may be useful in different countries.

A significant majority of experts favor integrating Ayurveda and allopathic medicine, considering that both medical systems must take measures to promote this process. The almost unanimous opinion emphasizes that Ayurveda can make outstanding and vital contributions to conventional medicine and that its knowledge by doctors would help improve patient care outcomes. There is also a majority consensus that conventional physicians should have training in Ayurveda at both the undergraduate and graduate levels and that they should have training in Ayurvedic medicines. A large proportion of the experts consulted to consider the prevailing view in the Ayurvedic government and official environment in India to favor integration with allopathy, and a significant but somewhat smaller number appreciate this same trend in the Ayurvedic academic field of India. There would be a current favorable to the integration on the part of the Ayurvedic doctors of India, but opposing opinions are appreciated on the part of the allopathic doctors of India. Significantly, almost two-thirds believe that in the West, Ayurveda should be a specialty within conventional medicine.

The integration of Ayurveda and allopathy has several potential advantages, including:

Holistic approach: Ayurveda focuses on the holistic approach to health, which includes physical, mental, emotional, and spiritual well-being. Integrating Ayurvedic principles into allopathy can help to provide more comprehensive and personalized health care.
Prevention: Ayurveda emphasizes the importance of preventing disease before it occurs through lifestyle modifications and the use of natural remedies. Integrating Ayurvedic principles into allopathy can shift the focus from treating disease to preventing it.
Safety: Ayurvedic interventions are generally considered safe and have fewer side effects compared to some allopathic medicines. Integrating Ayurveda with allopathy can help to reduce the risk of adverse reactions to conventional medicines.
Cost-effectiveness: Ayurvedic interventions are often more cost-effective than allopathic medicines. Integrating Ayurveda into conventional health care can reduce healthcare costs and improve access to healthcare for all.
Complementary approach: Integrating Ayurveda with allopathy can provide a complementary approach to health care. By combining the strengths of both systems, patients can benefit from a more holistic and personalized approach to health care.

It is highly likely that the publication of the benchmarks by the WHO, along with the actions taken by the Ministry of Ayush in India, as well as academic and research initiatives undertaken by renowned Ayurvedic institutions, and the growing interest in Ayurveda observed in the majority of countries, will stimulate a fruitful dialogue between these two medical systems that undoubtedly will benefit patients and the general population.

The sample was representative of the experts invited by the WHO and Ministry of Ayush to prepare the Benchmarks on Ayurveda. Although the response rate was good for a survey instrument, the sample was small, and it cannot be ensured that the experts’ answers represent the majority opinion on the subject. Since the study is cross-sectional rather than longitudinal, we do not have information on the actual attitude change over time. Due to the study’s limitations, it is necessary to carry out more representative studies of the opinions on the subject in the different WHO regions.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Ayurveda; WHO benchmarks; integrative medicine

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Ayurvedic Medicine: Ancient Wisdom and Modern Science

Ayurveda is a practice that focuses on maintaining a balance of energy within the body and emphasizes prevention rather than treating diseases, whereas conventional Western medicine uses drugs and surgery to address symptoms and diseases. Although Ayurveda cannot replace Western medicine, it can complement it by strengthening the body and preventing imbalances before they lead to recognizable diseases. It offers a holistic approach to well-being.

History of Ayurveda

Ayurveda is a traditional healing system that promotes a deep connection with nature and personal well-being, with a rich history spanning over 2,100 years. Its roots can be traced back to at least 200–101 BC, and it has been passed down through generations.

Ayurvedic knowledge includes medicinal plants and holistic health practices, which have stood the test of time, making it a trusted and enduring way of healing. It emphasizes the importance of thoroughly understanding a person's condition before treatment.

Basic principles of Ayurveda

Ayurvedic medicine is rooted in balance, like the scientific principle of homeostasis and delves deep into the harmony between the body and nature.

The three doshas: Vata, Pitta, Kapha

Central to Ayurvedic philosophy are the three doshas, each representing a unique blend of the five fundamental elements: Air, Water, Space, Earth, and Fire. The doshas — Vata, Pitta, and Kapha — govern the intricate balance within our bodies.

Vata dosha. Vata is responsible for controlling all movement in the body, both internal and physical, as it is linked with air and space. It regulates fundamental processes like breathing, muscle functions, and cellular activities. When in balance, it enhances creativity and flexibility; however, imbalance can lead to feelings of fear and anxiety.
Pitta dosha. Rooted in fire and water, Pitta governs metabolism, digestion, absorption, and body temperature. It regulates hunger and thirst. Imbalance in Pitta can lead to anger and jealousy, while balanced Pitta enhances understanding and intelligence.
Kapha dosha. It consists of earth and water and offers essential stability to joints, muscles, and the body's framework. Balanced Kapha promotes love, calmness, and forgiveness. Yet, imbalances can evoke emotions like attachment, greed, and envy, emphasizing the significance of inner harmony for overall well-being. Ayurveda emphasizes balancing the three doshas and natural elements to maintain health, as any imbalance can cause illness.

Seven vital tissues of Ayurveda

In Ayurveda, the human body comprises seven essential tissues, known as sapta dhatus, each vital for health:

Rasa (tissue fluids). Tissue fluids nourish cells, ensuring proper functioning and vitality.
Meda (fat and connective tissue). Supports bodily structures, promoting flexibility and insulation.
Rakta (blood). Carries oxygen and nutrients, supporting cellular functions.
Asthi (bones). Provides a sturdy framework for the body, crucial for structure and movement.
Majja (marrow). It moisturizes the body, supports the immune system, and maintains vitality.
Mamsa (muscle). Facilitates movement and maintains structural integrity.
Shukra (semen). Essential for reproductive health, symbolizing vitality and fertility.

The body's seven tissues work together for proper functioning and vitality. Ayurvedic wellness emphasizes their importance for overall health and the interconnectedness of body systems.

Balance through elimination

In Ayurveda, maintaining equilibrium also involves waste elimination, known as Tri Malas:

Purisa (feces)	Feces, or stool elimination, support digestive health, ensuring efficient nutrient processing and waste removal.
Mutra (urine)	Reflects kidney function and hydration, a crucial indicator of the body's internal balance.
Sveda (sweat)	Regulates body temperature and removes toxins from our bodies.

Ayurveda highlights the importance of balancing the tri doshas (three energies), sapta dhatus (seven tissues), and tri malas (waste elimination) for overall well-being.

Holistic therapies in Ayurveda

Ayurvedic Panchakarma is a comprehensive system of therapies comprising over 30 treatments tailored to individual needs. This therapeutic process includes three main stages:

Poorva Karma (preparation). To help the body relax and eliminate toxins, it is prepared using a combination of oils and steam.
Pradhan Karma (main therapy). Procedures like Vamana (forced emesis) and Virechana (laxative therapy) are customized to individual needs.
Paschat Karma (recovery). Post-therapy regimens restore digestion and absorption, bringing balance.

These therapies, tailored to specific imbalances, enhance overall well-being.

Ayurveda also includes Äshtanga Ayurveda, covering eight specialized disciplines, h ighlighting the depth and efficacy of Ayurvedic practices :

Kayachikitsa. Internal medicine
Bhootavidya. Psychological disorder treatment
Kaumar. Bhritya Pediatric care
Rasayana. Geriatric studies
Vajikarana. Aphrodisiac and eugenics treatment
Shalya. Surgery
Shalakya. Ear, nose, throat, and eye treatment
Agada Tantra. Toxicology studies

Science backing Ayurveda

Many misconceptions about the scientific validity of Ayurvedic traditions exist. Applying traditional scientific trials to Ayurveda is challenging, as they do not fully capture the system's diverse therapies and unique ingredients. Despite these complexities, ongoing research trials have shown that Ayurveda is highly effective, bridging ancient wisdom with modern science.

Historical validity

The centuries-old Ayurvedic practices are safe and effective, supported by a rich historical lineage painstakingly recorded in reliable texts. Lack of direct scientific evidence doesn't mean ineffectiveness; each ingredient underwent extensive observation before earning its place in this ancient healing tradition.

Bridging tradition with modern validation

Over 700,000 qualified Ayurvedic clinicians in India seamlessly incorporate ancient Ayurvedic therapies and medicines into their practice. Rooted in 57 revered texts detailing ingredients, dosages, and uses, these practitioners embody centuries of accumulated wisdom.

However, integrating ancient wisdom with modern scientific validation faces unique challenges. Ayurvedic formulations are often complex, combining multiple herbs and minerals. Standardizing these intricate combinations for randomized controlled trials (RCTs) proves challenging due to their nuanced interactions. Moreover, Ayurveda emphasizes individualized treatments, seemingly incompatible with the one-size-fits-all approach of RCTs.

Research on individual responses to Ayurveda

Prakriti in Ayurveda is like our unique genetic makeup. It influences our responses to treatments and environments. Ayurgenomics merges genetics with Ayurveda to explore this concept. Studies have linked specific Prakriti types to metabolism, stress response, and disease susceptibility. These findings demonstrate the scientific basis for Ayurvedic concepts and show how our differences impact our health.

Clinical studies

The Ayurvedic recipe Chyawanprash has been extensively studied, showing benefits in protecting against colds, coughs, reducing stress, and enhancing the immune system. Subsequent human studies have confirmed its immune-boosting effects with regular consumption.

A study on 87 dyslipidemia patients found significant benefits of Arogyavardhini Vati, an ancient Ayurvedic remedy traditionally used in cardiovascular treatment. The treatment significantly reduced cholesterol, LDL, triglycerides, and the inflammatory marker CRP, while HDL (good cholesterol) levels increased, indicating positive cardiovascular effects.

In the USA, a study supported by the National Institutes of Health (NIH) found that rheumatoid arthritis could be treated with ayurvedic medicine just as well as methotrexate. Clinical benefits were observed in 100% of Ayurvedic medicine patients, 86% of methotrexate patients, and 82% of the combination group. The study is being expanded in India with substantial funding approval.

Unlike pharmaceutical generics, clinical trials on Ayurvedic recipes face hurdles due to high costs and a lack of exclusivity. This challenge hampers scientific exploration, hindering its integration into mainstream medicine.

Herbal research

Extensive scientific research has been conducted on individual Ayurvedic herbs, unveiling their potent medicinal properties. For instance, turmeric (Curcuma longa) has strong evidence supporting its medicinal properties, leading to widespread consumption globally, such as in the popular practice of consuming turmeric-infused golden milk.

The Ayurvedic Pharmacopoeia catalogs 650 plants, from foundational to ancient remedies. Turmeric (Curcuma longa) is a well-studied example. The United States Pharmacopoeia acknowledges 350+ of these plants.

Therapeutic modalities

Ayurveda offers a range of evidence-based therapies, including:

Abhyangam. Whole-body oil massage therapy has been extensively studied and documented in scientific journals, showcasing its effectiveness to significantly reduce stress, decrease heart rate, and reduce blood pressure in those with pre-hypertension.
Shirodhara. In this therapy, a stream of oil or liquid is poured steadily on the forehead while massaging the head. Research has demonstrated its neurological benefits and potential mechanisms.
Jaluka. Known as leech therapy in the U.S., it involves using medicinal leeches to relieve venous congestion, a method approved by the US FDA.
Kshara sutra. This technique involves tying a medicated thread to treat anal fistulas. Surgeons widely accept it as an alternative to surgery, with numerous studies supporting its effectiveness and reduced patient discomfort.

Continued research efforts

Research institutions are working to digitize Ayurvedic knowledge and make scientific data available online, dispelling the misconception that evidence is lacking. Ayurveda has a rich history of safe and effective use and is recognized for its documented traditional knowledge.

Overall, Ayurveda's age-old wisdom faces scientific scrutiny, with ongoing studies illuminating its potential. Despite challenges and the need for more research, Ayurveda's holistic approach offers promise in modern healthcare. Balancing tradition and scientific rigor, Ayurveda continues to shape a nuanced future in healing practices.

Ayurveda's individualized approach, recognizing unique body constitutions (Prakriti), showcases its adaptability to personalized medicine, highlighting its potential for tailored healthcare solutions.
The efficacy of Ayurvedic treatments is being confirmed by current research and clinical studies, which are bridging the gap between traditional Ayurvedic wisdom and contemporary scientific validation.
Clinical trials have demonstrated the effectiveness of Ayurvedic treatments such as Chyawanprash and Arogyavardhini Vati in improving cardiovascular health and the immune system.
Journal of Traditional and Complementary Medicine. A glimpse of Ayurveda – The forgotten history and principles of Indian traditional medicine.
Journal of Ayurveda and Integrative Medicine. Ayurveda: (W)here is the evidence.
Journal of Translational Medicine. DNA methylation analysis of phenotype specific stratified Indian population.
Journal of Integrative and Complementary Medicine. Pilot study investigating the effects of Ayurvedic Abhyanga massage on subjective stress experience.
Journal of Clinical Rheumatology. Double-blind, randomized, controlled, pilot study comparing classic ayurvedic medicine, methotrexate, and their combination in rheumatoid arthritis.

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Oil pulling for oral health: To swish or not to swish?

by Tufts University

After scrolling social media, you might be tempted to ditch your typical oral care regimen in favor of melted coconut oil, or other similar oils, for a practice known as oil pulling. A method of traditional Ayurvedic medicine native to India, oil pulling involves swishing oil in your mouth for about 10–15 minutes before spitting it out, and proponents of the process have touted various oral health benefits.

Y. Natalie Jeong, professor and chair of the Department of Periodontology at Tufts University School of Dental Medicine, explains the claims and what really needs to be done to take care of your teeth and gums.

Are there benefits to oil pulling for oral health?

Supporters of oil pulling believe it cleanses the mouth naturally without chemicals, enhancing dental hygiene . Additionally, some claims suggest it detoxifies the body, improves skin health, and alleviates symptoms of migraines and allergies.

Is there evidence to support these benefits?

Currently, there is no robust scientific evidence to confirm that oil pulling effectively reduces cavities, whitens teeth, or improves overall oral health . This doesn't necessarily mean it is ineffective; rather, it indicates that its efficacy has not been scientifically established through sufficient, well-designed research.

Challenges such as small sample sizes, lack of control groups, and uncontrolled variables contribute to this lack of definitive evidence. Consequently, the American Dental Association does not endorse oil pulling as a dental hygiene practice.

While oil pulling might help remove loose debris around the gums and teeth through its swishing action, it is less effective than brushing and flossing. Once a biofilm or plaque has formed, oil pulling is no more effective than rinsing with water, as it cannot disrupt plaque like mechanical methods such as brushing or flossing can

Can oil pulling be harmful to your oral health?

Oil pulling is generally considered safe and unlikely to cause harm directly. However, there is a risk if individuals become overly reliant on its perceived benefits and neglect established oral hygiene practices, such as brushing, flossing, and avoiding smoking.

Completely substituting traditional dental care with oil pulling can pose significant risks to oral health. Additionally, accidentally swallowing large amounts of oil during the process could lead to digestive issues like an upset stomach or diarrhea.

What do you tell your own patients about oil pulling?

I generally do not recommend oil pulling as there is no solid scientific evidence supporting its effectiveness. There are other, more effective methods proven to enhance oral health, such as:

Brushing your teeth: Brushing after meals helps remove food debris and plaque trapped between your teeth and gums. Remember to brush your tongue as well, as bacteria can thrive there.
Flossing: Flossing at least once a day helps remove food particles and plaque from between the teeth and along the gum line where your toothbrush can't reach.

While I wouldn't discourage those who want to from using oil pulling as a pre-brushing rinse, it's important to follow it with brushing and flossing. Adding oil pulling to your routine is unlikely to cause harm, but it should not be expected to provide significant benefits.

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J Ayurveda Integr Med
v.14(2); Mar-Apr 2023
PMC10307688

Integrating ayurvedic medicine into cancer research programs part 1: Ayurveda background and applications

Integration of Ayurveda into our current health care research programs is critical to making progress in global wellness and in disease prevention and control, especially for cancer. Ayurveda promotes restoration of the innate healing mechanisms existing in the body for optimal immunity, resilience, and health. Ayurveda also has an abundant resource of botanical products containing diverse pharmaco-active ingredients and millennia of experience of clinical applications for health benefits. But there is a lack of evidence–based research to demonstrate its efficacy and potential. This 2-part review is written from the perspective of a western-trained biomedical scientist and student of Ayurveda. It aims to educate research scientist peers about the opportunities and challenges for scientific validation of Ayurvedic herbal compounds, protocols, and modalities and inspire more research in this area. Part 1 will review several aspects of Ayurveda including principles of body constitution ( Prakriti ), digestion ( Agni and Ama ) and mind-body health, in relation to cancer. Part 2 [1] will focus on Ayurvedic botanical resources used for cancer and research studies will be discussed on selected herbal compounds. Research gaps and opportunities will be identified to guide development of research programs to validate safety and efficacy of these therapies. Importantly, the use of Ayurvedic modalities is not intended to substitute for allopathic treatments for cancer but as an integrative component for prevention and restoration of strength and immunity post treatment.

1. Introduction

This review introduces Ayurveda, the traditional medical system of India, which offers a unifying perspective to health with unique paradigms, theories, and protocols to contribute to cancer prevention and post therapy rehabilitation/rejuvenation. It has been over 50 years since the U.S. National Cancer Act of 1971 was enacted to support research into mechanisms and treatments for cancer. Researchers continue to look for unifying concepts to understand the development of cancer. Over the last decades, hundreds of genes, proteins, epigenetic factors, and metabolic pathways have been discovered to be involved in cancer progression. Increasingly complex regulatory factors have been found within the tissue microenvironment, the immune system, and the microbiome. This review will outline perspectives from Ayurveda of additional ecological factors that influence health and disease such as our physiological phenotypes, nutrition, diet and lifestyle, and physical and mental stress. Part 1 of this review covers several aspects of Ayurveda including principles of body constitution ( Prakriti ), digestion ( Agni and Ama ) and mind-body health, in relation to cancer. Part 2 [ 1 ] will focus on Ayurvedic botanical resources used for cancer and research studies will be discussed on selected herbal compounds. This work begins to explore some basic Ayurvedic concepts and potential integration into heath care research programs.

Ayurveda is a comprehensive integrative healing system more than 5000 years old. “Ayurveda” by definition, is the science of life; Ayus meaning life and Veda meaning knowledge. The three main Ancient texts include the Charaka Samhita, the prime work with basic principles of Ayurveda and internal medicine [ 2 ] the Sushruta Samhitas, dealing with surgery and medical concepts [ 3 ], and the Ashtanga Hridaya, a more concise and poetic summary of the first 2 texts [ 4 ]. The highly detailed texts include recommendations for healthy diets, daily and seasonal routines, and extensive descriptions of over four hundred herbs and thousands of herbal formulations for specifice health conditions. Ayurveda offers a holistic, personalized medicine approach that considers an individual's body type, strength of digestion, immunity, and mental health. The concepts of physiology found in the ancient Ayurvedic texts are remarkably compatible with the modern allopathic understanding of physiology. The texts provide an understanding of normal physiology and pathology with unique perspectives on early stages of disease applicable to early detection strategies. They provide relatively simple, low-tech guidelines to restore and maintain the ecological balance of our bodies and interactions in our physical, social, and natural environments.

Ayurveda has a large resource of herbal medicines and formulations, the chemical constituents of which may target numerous biochemical and cellular pathways. These aim to balance the physiology and support immunity. The practice of Ayurveda also includes the criteria determining when to use these herbs and how to combine with diet, behavior, detoxification, and mind/body techniques to restore health and prevent disease.

Research studies in Ayurveda in Scopus shows a peak in 2020 with most of the authors from India (See Fig. 1 ). Much of the research in Ayurveda has reflected the current reductionist experimental paradigm to define mechanisms of isolated chemical components from single herbs such as curcumin or ashwagandha for drug discovery. Yet most diseases, including cancer, have multi-factorial causation and multiple molecular targets. Traditional Ayurvedic herbal preparations combine multiple herbs each with many potentially synergistic chemical compounds and have centuries of clinical application. These complex formulations for complex diseases may possess inherent value. How they have been used in populations over millennia may provide clues to their possible mechanisms and applications, to the discovery of new biomarkers of health and for unique perspectives for prevention and treatments for early and late stages of disease. Research studies on the clinical use of Ayurvedic herbs and protocols are still lacking.

Publications on Ayurveda. A search in the Scopus reference data base for the text “Ayurveda” in the title, abstract or key words, produced >7500 documents between 1990 and 2022. They are shown as number of documents per year. Trends of research publications in Ayurveda show a peak in 2020 with most of the authors from India.

Compared to allopathic medicine which is largely disease-focused, and where health is defined mostly as the absence of disease, Ayurveda is person-focused, where health is defined as the optimal functioning of the psycho-physiological systems of the body, the tissues, strength of digestion, the proper elimination of wastes, and immunity. Imbalances between these elements can lead to dysfunction, inflammation, and progression of disease. This review aims to encourage research into mechanisms and safety of Ayurvedic herbs and efficacy of protocols to be integrated into cancer care and prevention.

This paper will briefly introduce several principles and concepts of Ayurveda which may be new to some readers, and somewhat abstract. For a more thorough discussion and deeper understanding of these concepts, a few references are mentioned here. Several comprehensive reviews of the principles of Ayurveda are found here [ [5] , [6] , [7] ] and for scientific decoding of some of the core concepts of Ayurveda, see Ref. [ 8 ]. Also of interest may be a contemporary review of the perspective of cancer found in the traditional texts of Ayurveda, the Charaka and Sushruta Samhitas, including classification, pathogenesis and traditional treatments [ [9] , [10] , [11] ].

Most of the public perception of Ayurveda and most of the research to date relates to the Ayurvedic herbs or rasayanas (traditional combinations of herbs that support strength, immunity, and longevity). This will be discussed in Part 2 of this review. Beyond the herbs, there is a vast knowledge in the original Ayurvedic texts that contain comprehensive guidelines and protocols for health promotion including addressing body constitution (“ Prakriti ”), optimizing digestion, and the mind/body/spirit connection (See Fig. 2 ). These three concepts will be discussed here in Part 1 along with the status of evidence-based validation of these Ayurveda modalities. The discussion section within Part 2 will conclude with research challenges and directions for developing research agendas.

Ayurveda- Contributions to Health and Prevention of Disease. This review is divided into 2 parts containing 4 main aspects of Ayurveda that contribute to health and prevention of disease and are discussed in relationship to cancer etiology. Part 1 will cover sections A, B and C. A) Prakriti or body constitution is represented by Vata, Pitta and Kapha expressing the qualities of the basic elements of nature, Space, Air, Fire, Water and Earth. B) Digestion is a critical component of health and depends on strong Agni – or digestive fire. When Agni is insufficient, then Ama , a metabolic toxin accumulates in the tissues resulting in seeds of disease. C) The state and balance of Mind, Body, and Spirit will be discussed as a fundamental component to health. Part 2 of this review is a companion document in this issue and will address D) Rasayanas and herbs in Ayurveda (representative picture of Guduchi, ( Tinospora cordifolia ), as well as research questions and directions, gaps, and opportunities.

1.1. Role of body constitution/ Prakriti in health and disease

A concept pivotal to the Ayurvedic philosophy and science is that different people have different body types or constitutions which contribute to the heterogeneity in disease predisposition, responses to environment, drug effects or resistance. It is understood that in clinical trials men may respond to treatments differently than women; also, children respond differently than adults. Ayurveda would incorporate another distinction for populations considering the constitution of the body called “ Prakriti” [ 12 ]. This theory considers the human physiology in relation to the five subtle elements: space, air, fire, water, and earth, termed P anchamahabhuta. These 5 elements correspond to the 5 senses, hearing, touch, sight, taste, and smell, respectively. Ayurveda proposes that in biological systems, including humans, these elements are coded into three forces, which govern all life processes and are expressed in the physiology as the Doshas : Vata (V), Pitta (P) and Kapha (K) (See Fig. 2 A) . Each dosha has five subdoshas that relate their functions within the body's organ systems [ 13 ]. The tenets of this “ Tridosha theory” is that these three physical and psychological control systems mutually coordinate to perform the normal function of the body [ 14 ].

1.1.1. Vata, Pitta and Kapha doshas

Vata dosha incorporates the elements of air and space and regulates movement, intelligence, direction, and purpose in the body. Physiologically this would include breathing, speaking, blood flow, heart, the nervous system, movement of food through the digestive tract, or communication between cells and nerves. Pitta dosha includes the water and fire elements and contributes to the transformational/metabolic mechanisms of the body, including digestion, appetite, enzymatic functions, and the blood system that carries oxygen and nutrition throughout the body. Kapha dosha incorporates the earth and water elements and forms the structure, strength and lubrication of the body and found in the bones, joints, muscles, and secretory functions. An analogy for how these three processes coordinate is seen in Fig. 3 in the functioning of a car. The Kapha elements of earth and water, structure, and lubrication, are represented by the body and wheels of the car, Pitta elements of fire and water; transformation and metabolism are represented by the engine and drive train, and Vata elements of space and air, movement and intelligence are represented by the motion and direction of movement. All aspects interact and are necessary for efficient functioning of the car, as they are also important for our physiology.

Analogy: Three Doshas as expressed in a car. The three doshas of Prakriti can be understood using an analogy of a car. The Kapha elements of earth and water, structure, and lubrication, are represented by the body and wheels and engine oil of the car, Pitta elements of fire and water; transformation and metabolism are represented by the engine, and drive train, and Vata elements of space and air, movement and intelligence are represented by the motion, control of movement, and the intelligence from the driver and dashboard GPS. All aspects interact and are necessary for efficient functioning of the car, like how these 3 doshas interact and support our physiology and psychology.

Each person has their own unique Prakriti in which the doshas predominate in their physiology as either a single dosha – V, P, or K, or combinations of any of the doshas - VP, PK, VK, and VPK . An individual's Prakriti can determine how they respond to the external environment including susceptibility to diseases or responses to drugs [ 15 ]. When the doshas are in balance, each body type has unique positive tendencies and health attributes, and when the doshas are out of balance these persons have equally unique vulnerabilities (See Fig. 4 ). The aim of Ayurveda is to maintain balance between these doshas as well as within the seven tissues ( dhatus ) and the three channels for waste products ( malas ) ([ 5 ]; pages 87–90). Imbalances between these elements can lead to decreased vitality and immunity and to inflammation and disease.

Qualities and expression of Vata Pitta and Kapha . Ayurveda proposes that in biological systems, including humans, there are three operators which govern all life processes and are expressed in the physiology as the Doshas : Vata, Pitta and Kapha. They coordinate functioning both in our bodies and in the whole of nature. The qualities of Air and Space are listed as Vata, qualities of Fire and Water are listed as Pitta, the qualities of Earth and Water are listed as Kapha. Characteristics of Vata Pitta and Kapha are listed for how they express in the physiology when they are in balance, and when out of balance.

1.1.2. Assessment of Prakriti

Traditionally Prakriti is assessed subjectively by an Ayurvedic physician, usually by observation, interrogation, and analysis of the pulse. Both Ayurveda and Traditional Chinese Medicine include diagnoses and treatments based on psycho-physiological characteristics of individuals. The determinants of Prakriti are well described and elaborated in Rotti, 2014 [ 16 ] and include an extensive list of parameters such as morphological features, tactile features, subjective physical findings, routine and lifestyle, and intellectual and emotional attributes. This team also developed a computer-aided tool, AyuSoft, to evaluate these parameters to determine the Prakriti of 3416 subjects in three centers in south India. When they compared the computer results to assessments by senior Ayurvedic physicians, they found 80% concordance in the results. Another quantitative measure of Tridosha was obtained by using an algorithmic experimental method to include the comprehensive list of qualitative features that are commonly used by Ayurvedic doctors [ 17 ].

1.1.3. Research in Prakriti

Research studies in Prakriti have established that there are genetic and epigenetic correlates for the three body types [ 18 , 19 ]. One of the earliest papers from 2005 hypothesized a link between genetics and Prakriti . They evaluated 76 subjects both for their Prakriti and human leucocyte antigen (HLA) DRB1 types and found distinct HLA alleles within the different K, P, or V types supporting the idea of the association between HLA alleles and individual Prakriti types [ 20 ]. Collaborations in this field of “Ayurgenomics” have quantitated differences in gene expression, SNP variations, epigentics, and immunophenotyping that correlate with Prakriti and distinctions between the V, P, and K body types. One of these reports determined that people with contrasting Prakriti exhibit significant differences genes related to metabolism, transport, immunity, and cell cycle [ 21 ].

Another study showed variability of a key oxygen sensor gene, EGLN1, based on Prakriti types which was linked to high altitude adaptation [ 22 ]. Biochemical differences were also found in liver function, lipid profiles, and haemoglobin between Prakriti types [ 23 ]. Other studies demonstrated genetic differences in populations based on their Prakriti , such as correlations between CYP2C19 genotypes and Prakriti , which was associated with fast and slow metabolism [ 24 ]. In another study a significant difference was seen in 52 SNPS between Prakriti types and one gene, PGM1, correlated with phenotype of Pitta [ 25 ].

Prakriti is strongly influenced by epigenetic changes due to lifestyle, diet and environmental influences [ 26 ]. Epigentic differences were found in DNA methylation analysis of Prakriti -specific multiple CpG sites in promoters and 5′-UTR such as: LHX1 ( Vata Prakriti ), SOX11 ( Pitta Prakriti ) and CDH22 ( Kapha Prakriti ) [ 27 ]. Immunophenotyping of whole blood displayed significant differences in the expression of CD14, CD25 and CD56 markers where CD25 and CD56 expression was significantly higher in Kapha Prakriti samples than other Prakriti groups [ 28 ]. Finally, in a pilot study on rheumatoid arthritis, genetic susceptibility markers were found using Prakriti- based subgroups. Inflammatory genes IL1β and CD40 correlated as determinants in the Vata subgroup whereas oxidative stress pathway genes were observed in the Pitta (SOD3; rs2536512 and PON1) and Kapha (SOD3 rs2536512) subgroups [ 29 ].

Clinical methods of Prakriti evaluation have been summarized and validated through advanced machine learning approaches [ 12 ]. A computational system classified 147 healthy individuals into different Prakriti types where phenotype data fell into three distinct clusters, matching the extreme Prakriti groups as classified by clinicians. This study demonstrated that Prakriti types are “distinct verifiable clusters within a multidimensional space of multiple interrelated phenotypic traits.”

Throughout these studies, different research groups approach the determination of Prakriti through different methods. For rigorous research in this area, it is necessary to develop standard tools or protocols to determine the Prakriti . And for reproducibility, it is essential for Prakriti -based researchers to include the full questionnaires, or tools they use for Prakriti assessment within their publications [ 30 ]. Ayurveda provides an historical example of personalized medicine and an opportunity for clinicians to stratify physical and behavioral phenotypes and treat patients according to their Prakrit/ psychophysiological constitution.

The Ayurveda concept of Prakriti represents an individualized precision medicine approach and may offer discovery of novel biomarkers for complex diseases. The examples above could contribute to the development of predictive and prognostic markers of disease as well as therapeutic responses. Prakriti may also be another variable used to analyze clinical trial results as to which populations are responsive to treatments, and why others may not be responsive. These research opportunities and others are outlined in the discussion section 4.1 .

2. Importance of digestion for optimal health

Both the ancient physician Hippocrates and Ayurvedic physicians understood that “All disease begins in the gut”. Therefore, managing digestion and diet are vital to maintaining health. All the building blocks of the physiology, the cells, and tissues, depend on the quality and purity of the food, air, and liquid we take in. Not only what we eat is important but so also how the food is prepared, when we eat, and how well we digest the food. The Ayurvedic perspective is that improper food consumption, routines or behaviors are causative factors that impair the digestion process. Poor digestion promotes toxic buildup of metabolic waste products that promote inflammation and interfere with cellular and immune functioning. Because the Ayurvedic tradition provides a holistic approach it is not unusual to find that a treatment for a cancer may not only directly target the cancer cellular pathways, but it would also support digestion or support elimination of accumulated toxins. An example is the Ayurvedic formula Triphala that promotes efficient digestion, absorption, and elimination. It also has anti-cancer properties, as will be discussed in Part 2 of this review [ 31 ].

2.1. Agni and Ama

Two important Ayurvedic principles related to digestion are Agni and Ama. Agni is the transformational ‘fire’ that is responsible for digestive and metabolic processes and provides fuel for mental and physical activity. Classically there are 13 types of Agni; the focus here is on the component “ Jatharagni” , the metabolic processes in the digestive system which digests and transforms food into nourishment (rasa) and waste products (mala). The Ayurvedic hypothesis is that when there is balanced Agni , food is completely digested and broken down to the macromolecules of amino acids, sugars, and lipids, etc. Agni may be strong, irregular, or dull, based on the predominant dosha s and on diet, behavioral, and environmental causative factors [ 32 ]. Ayurveda theorizes that due to these causative factors and others, the Agni becomes weak, and the food is not completely digested, leaving macromolecules and toxins called Ama.

The body has a constant flow of nutrients, oxygen, and waste products. When these processes are blocked and toxic waste products become lodged in the tissues as Ama it creates seeds for diseases [ 33 ]. Ama is described as “uncooked food” or incomplete transformation of nutrients, or toxins, such as metabolic toxins or environmental impurities, reactive oxygen species, or unstable metabolic end products [ 34 ]. These toxins can become localized outside of the digestive system due to increased intestinal permeability. Ama gets into the circulation and clogs the channels ( Srotas ) and can be abnormally deposited in the tissues ( Dhatus ). The immune system recognizes this Ama as a foreign material and initiates an inflammatory response. If Ama is deposited in the joints, it can result in arthritis, or Ama deposited in the arteries leads to atherosclerosis., etc. Incomplete digestion therefore becomes a source of inflammation, an important aspect of early stages of disease. This reference discuses diet and Ama as a precursor to chronic inflammation and the potential role in the progression of cancer [ 35 ].

2.2. Inflammation and the role of the gut microbiome

Inflammation is understood to be an important pre-cancerous condition. Chronic inflammation is carcinogenic, as seen in gastritis or inflammatory bowel disease, pancreatitis, reflux esophagitis, asbestosis-induced mesothelioma, etc. [ 36 ]. The quality and content of our food plays a major role in inflammatory and immune responses either directly through micronutrients or through conditioning the composition of the gut microbiome. Nearly 30 trillion microorganisms are living in or on each person with 500–1000 different species. The lower gut contains 99% of microorganisms in body. The microbes in the lumen of the gut have profound influences on the immune system at the local level and systemically [ 37 ]. When gut bacteria become disruptive, it can cause increased inflammation and increased intestinal permeability and may promote distribution of digested and undigested products as well as immune factors and bacteria throughout body tissues [ 38 ]. This progression provides a modern interpretation of the ancient Ayurvedic concept of Ama [ 39 ]. The gut microbiome has been implicated in inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis [ 40 ]. A vibrant research area has evolved related to the role of the gut microbiome in cancer [ 41 , 42 ]. For instance, in melanoma patients treated with anti-PD-1 checkpoint blockade immunotherapy, significant differences were found in the composition of the gut microbiome in patients that responded to the treatment versus those that did not respond [ 43 ]. This underlies the importance of digestion and the microbiome in cancer and disease.

2.3. Ayurvedic perspectives for digestion and the gut microbiome

Dietary habits and lifestyle factors have an impact on intestinal permeability and barrier function. There are known detrimental effects of the western high fat and sugar diet, high alcohol intake, stress, and certain medications on gut microbiota [ 44 ]. Ayurveda has protocols specifically for diet, digestion, detoxification, and supporting metabolism [ 45 ]. Digestive capacity and efficiency can be variable and dependent on Prakriti . A Vata predominant person may have irregular digestion, sometimes strong, or sometimes they have no appetite; a Pitta Prakriti has a good appetite and digestion but has a tendency towards heartburn or if not fed, becomes “hangry”. A Kapha constitution is prone to weaker Agni and has slower digestion and heaviness [ 46 ].

The gut microbiome may play a role in the Prakriti- specific digestive capacity. The gut microbiome has been shown to be different in different Prakriti types. A comprehensive analysis demonstrated a correlation of the predominant Prakriti ( Vata , Pitta and Kapha ) with analysis of human microbiome from the gut, oral and skin samples of healthy individuals. Samples showed Prakriti -specific differences in abundance and types of multiple bacteria species [ 47 ]. Another study was carried out in a healthy genetically homogenous western Indian rural population of similar ages and dietary habits and showed gut microbial diversity based on Prakriti [ 48 ]. By using 16S rRNA gene based microbial community profiling they found multiple species of the core microbiome to have differential abundance based on Prakriti types with Prakriti -specific enrichment of bacteria. These studies highlight the importance and value of including Prakriti in analysis to explain the variability of the gut microbiome amongst healthy individuals that could have consequences for an individual's health, disease, and treatment.

The taste of food has an essential value in Ayurveda. Six tastes are defined (sweet, sour, salty, bitter, astringent, and pungent) that can aggravate or pacify Vata, Pitta, and Kapha . Ayurveda values the role of spices not just for flavor but also to support digestion and absorption. An analysis of commonly used therapeutic spices in Ayurveda (turmeric, ginger, black pepper, and pippili) found substrates that improved collective metabolism in gut microbiome communities to support efficient digestion [ 49 ]. Ginger, black pepper, and pippili are often combined in equal quantities in the common Ayurvedic formulation called Trikatu, which was found to enhance digestion and increase the bioavailability of a number of drugs [ 50 ].

2.4. Ayurvedic description of cancer pathogenesis and early detection of diseases

The traditional Ayurvedic texts describe cancers as inflammatory or non-inflammatory swellings called Arbuda (major neoplasm) or Granthi (minor neoplasm). The translation of these terms has been described differently over time with “ Arbuda ” translated as round, large, muscular, immovable, or swelling ‘tumor’ and G ranthi as a benign cystic node or nodule or swelling, or glandular enlargement. For a deeper understanding of the Ayurvedic perspective of cancer see Balachandran 2005 [ 9 ].

Ayurvedic texts have embedded theories of the early detection, etiology and pathogenesis of disease, called Samprapti ” or progression of disease. It is described as six stages of pathogenesis “ Shat Kriya Kala ”. [for further explanation see Ref. [ 10 ]]. This is a process that can happen over years, and is a progression of aggravation of the doshas weakened by wrong diet or causative factors, and accumulation of Ama and inflammation in the tissues. An important aspect of this theory is that imbalances in the body can be detected in the early stages of disease and Ayurvedic treatments can reverse the disease processs.

This pathogenic process of the interaction of the Tridoshas and how they are involved in cancer development and progression was reported in the context of a summary of interviews with 10 Ayurvedic physicians ( Vaidyas ). Dhruva et al. reported the consensus of the Vaidyas’ Ayurvedic descriptions of the pathophysiology of cancer, and approaches for the treatments of cancer. The paper also describes how biomedical treatments often result in depletion and degeneration of the body compared to Ayurvedic treatment which focuses on strengthening digestion, reducing Ama and improving tissue metabolism or Agni . They summarize that “the Tridosha perspective on cancer includes the involvement of Kapha to induce growth of tissue, Pitta in transforming the tissue from normal to malignant and the role of Vata in the spread of cancer outside of the organ such as metastasis.” [ 51 ].

Ayurvedic treatments aim to promote the body's self-healing properties and restore the body's natural defenses and immunity, and rejuvenate major body systems and promote long-term recovery from a disease. The Ayurvedic program of Panchakarma, is used as a multi-day cleansing regimen with specific techniques to strengthen Agni , clean out the Srotas, move toxins such as Ama out of the body and assist in the body's self-repair capacity [ 52 ]. This theory of Shat Kriya Kala is not yet scientifically validated but would be an interesting and fruitful area of research as applied to early detection of cancers. Other research opportunities related to Ayurveda and digestion are outlined in section 4.2 .

3. The role of the mind, body, and spirit

Another influential component in cancer etiology is the relationship of body, mind, and spirit or consciousness. Early childhood exposure to adversity and stress can lead to neuroendocrine, epigenetic and psychological predispositions to cancer at a later age [ 53 ]. Ayurveda addresses the mind-body-spirit through techniques of yoga and meditation to remove stress and develop consciousness.

3.1. Research in mind, body, and spirit in relation to cancer

There is increased interest and research in the effect of the mind and spirit on the body and, in reverse, the role of physiology on mental function. The mind and thoughts are connected to neurotropic factors that influence and are influenced by immune function, all of which can affect the cancer microenvironment. This is called psychoneuroimmunology and its role in cancer progression is detailed in Green et al., 2013 [ 54 ].

Research has found associations between depression or stress-related psychosocial factors and cancer outcome. There is increased cancer incidence and mortality, and poor prognosis in populations exposed to chronic stress and depression. A meta study found an increased incidence in lung cancer in populations with psychosocial stress as well as decreased survival in populations with cancers of the head and neck, breast, lung, lymphoid or hematopoietic tissues [ 55 ]. Mental stress can also affect the biology of tumors such as in the stimulation of the adrenal hormone cortisol, and activation of the sympathetic nervous system and the downstream target effects. A comprehensive review is here [ 56 ]. These hormones influence the immune responses and inflammation, and alter tumor angiogenesis, mesenchymal differentiation, and metastasis [ 57 ]. This is observed in underrepresented minorities and underserved communities where exposure to stress has an increased impact on cancer survival and quality of life of patients with cancer [ 56 ]. The effects of stress may be moderated by an Ayurvedic lifestyle including proper diet, routine and especially stress-reducing techniques of breathing, yoga, and meditation which promote experiences of quieter levels of the mind, and different states of consciousness.

Research studies of the effects of practices of yoga and meditation for health purposes include up to 7071 publications for yoga, with 707 publications related to yoga and cancer, and 878 publications on meditation and cancer (PubMed/August 2022). An 8-week yoga therapy course was given in a randomized controlled trial to 159 patients of different cancer types. Yoga was found to reduce depression and fatigue in cancer patients with the greatest benefit to breast cancer patients [ 58 ]. Yoga was part of a multi-modality Ayurvedic nutrition and lifestyle intervention program in breast cancer survivors [ 59 ] which explored the feasibility and potential benefit of this approach to reducing symptoms of fatigue, sleep disturbance, anxiety, depression, and perceived stress. The study concluded that the Ayurvedic intervention may “contribute to clinically meaningful improvements in this survivorship population which merits future study in a randomized control trial”. A pilot study on yoga and obesity was important in providing a methodological design and template for Ayurvedic research [ 60 ].

The effects of stress reduction on cancer using meditation were explored in a single-blind, randomized control trial in 130 breast cancer patients. Quality of life measures from Functional Assessment of Cancer Therapy- Breast (FACT-B) indicated a positive effect in group using transcendental meditation (TM) plus standard of care (SOC) compared to SOC alone [ 61 ]. Also, a survey of use of medical care in TM practitioners found hospital admissions for tumors was decreased by 55.4% compared to other members in the same insurance carrier [ 62 ]. And finally, a recent study explored stress-related gene expression profiles of peripheral blood mononuclear cells from long term TM meditators compared to matched controls. Various genes were described with differential expression that correlates to stress effects indicating possible molecular mechanisms for future research [ 63 ].

There are many different types of yoga or meditation practices, therefore actual mechanisms may vary; and many practices are not necessarily from the Ayurvedic tradition. Well designed clinical trials and case studies are encouraged to increase evidence of yoga and meditation techniques for prevention of stress-induced tumor progression and inflammation, and for patient support during cancer therapies and in post treatment rejuvenative care. These studies give an important basis for developing clinical trials in research programs to understand the synergistic effects of combinations of mental techniques, herbs, diet, and routines of in Ayurvedic interventions for promoting health. Research opportunities related to Ayurveda and mind/body health are outlined in the discussion section 4.3 .

4. Discussion: research challenges and directions

This Review serves as an introduction to Ayurvedic medicine for biomedical research scientists. It has provided an overview of a few of the many theories from Ayurveda and has reviewed some of the already extensive body of research in the traditional tenets of Prakriti , digestion, Agni , and Ama and the realm of mind, body, and spirit or consciousness, and their practical applications to cancer research. The next step is to encourage development of statistically strong and reproducible research methods for integration of these concepts into current health care studies especially for cancer research. This section provides some potential questions related to research gaps and opportunities as stimuli towards developing research programs.

4.1. Research directions: Prakriti

How can body composition and the three doshas, Vata, Pitta and Kapha be integrated into cancer research? Questions are proposed here relate to the role of Prakriti in clinical applications, genomics and epigenomics analysis and expression of the doshas on a cellular level.

a. How does a patient's Prakriti contribute to differential responses to clinical treatment regimens?
b. Can Prakriti be used for preselection of patients to treatment arms in clinical trials?
i. What are biomarkers of increase or decrease of each dosha ?
d. Do different body types get different cancers? (brain ( V ?) vs pancreas ( P ?) vs breast cancer ( K ?))?
e. How do we standardize assessment of Prakriti using pulse diagnosis, questionnaires, or algorithms for use in clinical trials?
a. Can we validate the molecular biomarkers of body constitution or Prakriti using genomic or epigenomic expression profiles? (See recent publication for efforts in this area [ 64 ].
i. Prospective: Prakriti is determined at time of biospecimen collection and added to patient data
ii. Retrospective: For myriads of existing data bases, can we access electronic health records and ‘back-decipher’ the Prakriti – using body frame, disease propensity, body mass index, face/bone structure, etc.? Can we build an artificial intelligence algorithm of the Prakriti factors to include in the analysis of treatment results data?
a. Can the Vata qualities of communication, transportation and intelligence be attributed to biomarkers involved in signal transduction, cell movement, or DNA code. Can the vagus nerve be a biomarker for Vata activity? [ 65 ].
b. Are Pitta qualities of transformation and metabolism seen in mitochondria production of ATP, DNA synthesis, transcription, and translation, enzymatic activities?
c. Can the Kapha qualities of structure, lubrication and stability be correlated to the actin cytoskeleton, DNA structure, and cellular membranes?
d. How can VPK be represented on the molecular and cellular levels and be developed as biomarkers?
4. Can we find biomarkers of diminished or increased V, P, and K ? Such as, for “aggravated Vata ” how would you measure the Vata qualities of dry, light, moving, etc. in the physiology or mind? Similar questions were raised in a review by Wallace [ 66 ]:

4.2. Research directions: digestion

Questions for research in Ayurvedic perspectives on digestion explore the physiological cellular and molecular mechanisms behind the concepts of Ama and Agni and the importance of digestion as basis for disease including cancer. Such questions include:

1. What physiological mechanisms explain how poor digestion promotes toxic buildup of metabolic waste products that interfere with cellular and immune functioning?
2. What are physiological correlates of different states of Agni ? How could it be quantified for clinical analysis? What are biomarkers of increased Agni ?
a. How can we quantitate increased or decreased Ama in the physiology?
b. How does Ama induce inflammatory components?
c. What are parallels between Ama and increased intestinal permeability? What is role of the microbiome in this process?
d. How is the microbiome different in people of different Prakritis ( V, P & K )?
4. How are toxins ( Ama ) embedded in the body and manifest as disease?
5. How does the immune system recognize Ama as a foreign material and initiate the immune inflammation process?
6. What are the physiological correlatives to the Ayurvedic protocols for digestion support to strengthen Agni and minimize Ama?
• Efficacy of detoxification procedures
• Ability to recover from radiation or chemotherapy toxicity
• Changes in quality of life after Panchakarma.

4.3. Research directions: mind body-spirit

Protocols for research in this area may appear more subjective in defining physiological correlates of mental states and how the health of the body is reflected in the mind. Research studies on mind-body and cancer could examine these topics:

1. What are the mechanisms of how stress affects tumor cell growth and cancer progression?
2. Explore the link between the mind and digestion as through the gut microbiome?
3. Explore use of Ayurvedic modalities in restorative and palliative care.

5. Summary for Part 1

Part 1 of this review has introduced some basic Ayurvedic concepts including body constitution ( Prakriti ), digestion ( Agni and Ama) and mind-body-spirit health and their contributions to disease pathogenesis and their integration into cancer research. It is difficult to represent the depth of the of these concepts from the traditional Ayurvedic texts in the space of this document, and they deserve further study and development for potential applications. As we build research programs in Ayurveda, we need to bridge several gaps of communications. One gap is in the translation of the theories of this traditional medicine into current molecular and cellular terminology and clinical applications. These concepts, often expressed in the Sanskrit language, are unfamiliar and alienating to western biomedical researchers. The opportunity to understand and translate Ayurvedic principles such as Agni, Ama , Prakriti and others, may also contribute to our understanding of physiology and our approach to healing.

Part 2 of this review ([ 1 ]) will explore some of the Ayurvedic herbal products, and selected research on their biochemical mechanisms and clinical applications. Also, in Part 2 there will be a summary discussion of gaps and opportunities for research programs in Ayurveda and a consideration of experimental methodologies and clinical studies.

This 2-part review supports the integration of Ayurveda into current health care as a well-timed, low-cost approach to support immunity and optimal disease prevention for the general population and especially for cancer care. The additional value is the discovery of biomarkers of health and of unique perspectives for prevention and treatments for early and late stages of disease.

This review is prepared as a personal activity of Dr. Julia T. Arnold. The opinions expressed in this article are the author's own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government.

Funding sources

This review did not receive any specific grant from funding agencies in government, public, commercial, or not-for -profit sectors.

Conflict of interest

Acknowledgements.

Thank you to Dr. Perry Skeath and Shraddha Ravani for their conceptual input.

Dr. Arnold is sole author and contributor to the thoughts and ideas expressed here and agrees to the manuscript in its submitted state.

Peer review under responsibility of Transdisciplinary University, Bangalore.

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